Basic Suturing Workshop By Shauna O’Sullivan Resident Orientation Course 2012.

Basic Suturing Workshop

By Shauna O’SullivanResident Orientation Course 2012

Objectives

• Describe the principles of wound healing

• Identify the various types and sizes of suture

material

• Identify the different injectable anesthetic agents

• Demonstrate different types of closure techniques

• Recommend appropriate wound care and follow-up

Critical Wound Healing Period

Tissue

Skin

Mucosa

Subcutaneous

Peritoneum

Fascia

5-7 days

5-7 days

7-14 days

7-14 days

14-28 days

0 5 7 14 28

Tissue Healing Time/Days

Model of Wound Healing

• (1) Hemostasis: within minutes after injury, platelets

aggregate at the injury site to form a fibrin clot

• (2) Inflammatory: bacteria and debris are

phagocytosed and removed

– Factors are released that cause the migration and division

of cells involved in the proliferative phase

Model of Wound Healing

• (3) Proliferative: angiogenesis, collagen deposition,

granulation tissue formation, epithelialization, and

wound contraction

• (4) Remodeling: collagen is remodeled and realigned

along tension lines and cells that are no longer

needed are removed by apoptosis

Wound Healing Concepts

• Patient factors

• Wound classification

• Mechanism of injury

• Tetanus, antibiotics,

local anesthetics

• Surgical principles and

wound prep

• Suture, needle, stitch

choice

• Management, follow-up

CDC Surgical Wound Classification

• Type 1 “Clean” Wounds:

– 1-5% risk of infection

– Non-traumatic

– No inflammation present

– No break in technique

– Example: elective groin hernia repair


• Type II Clean-Contaminated Wounds:


– Non-sterile body region entered under controlled

conditions and without unusual contamination

• (GI or GU tract, biliary tract, respiratory tract,

oropharynx and etc.

– Or minor breaks in technique


• Type III Contaminated Wounds:


– Major break in sterile technique

– Gross spillage from Gastrointestinal (GI) tract

– Infected GI, Urinary or biliary tract

– Fresh traumatic would (through unprepped skin)


• Type IV Dirty or infected Wounds:

– Infection risk of >27% risk

– Wounds associated with perforated viscus; cross clean

tissue to drain pus

– Traumatic wounds with:

• Imbedded foreign body

• Delayed presentation (> 12-24 hours for face and scalp; > 6

hours elsewhere)

Closure Types

• Primary closure (primary intention)

– Wound edges are brought together so that they

are adjacent to each other (re-approximated)

– Examples: well-repaired lacerations, well reduced

bone fractures, healing after flap surgery

Closure Types

• Secondary closure (secondary intention)

– Wound is left open and closes naturally

(granulation)

– Examples: gingivectomy, gingivoplasty, tooth

extraction sockets, poorly reduced fractures

Closure Types

• Tertiary closure (delayed primary closure)

– Wound is left open for a number of days and then

closed if it is found to be clean

– Examples: healing of wounds by use of tissue

grafts

Suture Materials

• Criteria

– Tensile strength

– Good knot security

– Workability in handling

– Low tissue reactivity

– Ability to resist bacterial infection

Types of Sutures

• Absorbable or non-absorbable

• Natural or synthetic

• Monofilament or multifilament (braided)

• New antibacterial sutures

Suture Size

• Sizes 3 to 12-0

– Numbers alone indicate progressively larger sutures,

whereas numbers followed by 0 indicate progressively

smaller

Smaller Smaller --------------------------------------------------------------------------LargerLarger

.....”3-0”...”2-0”...”1-.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....0”...”0”...”1”...”2”...”3”.....

Suture Material

Non-Absorbable

• Not biodegradable,

permanent

– Nylon

– Prolene

– Stainless steel

– Silk (natural, can break

down over years)

Absorbable

• Degraded via inflammatory

response

– Vicryl

– Monocryl

– PDS

– Chromic

– Cat gut (natural)

Indications

Non-absorbable

• Skin repair

• Fascia under tension

• Vascular (blood vessel)

repairs

Absorbable

• Subcutaneous repair

• Intraoral mucosa

(including tongue)

• Fascia not under

tension

Suture Material

Natural SutureNatural Suture• Biological orgin• Cause inflammatory

reaction– Catgut (connective

from cow or sheep)– Silk (from silkworm

fibers)– Chromic catgut

SyntheticSynthetic• Synthetic polymers• No inflammatory

response– Nylon– Vicryl– Monocryl– PDS– Prolene

Suture Material

MonofilamentMonofilament• Single strand of suture

material• Minimal tissue trauma• Smooth tying but more

knots needed• Resists harboring organisms• Nylon, Monocryl, Prolene,

PDS

Multifilament (braided)Multifilament (braided)• Fibers are braided or

twisted together• More tissue resistance• Easier to handle• Fewer knots needed• Vicryl (braided), Silk

(braided), Chromic (twisted)

Suture Materials

www.practicalplasticsurgery.org

Suture Selection Tips

• Do not use dyed sutures on the skin

• Non-absorbable use for skin, tendons and fascia

– Use up to 6 months

– Less scarring but must be removed

• Absorable used for GI, urinary and biliary

• Use monofilament on the skin as multifilament harbor

BACTERIA

Suture Sizes

General rule : 6-0 on face, 5-0 on hand, & 4-0 elsewhere on body


Surgical Needles

• Classified according to shape and type of point– Curved or straight

– Tapered point, cutting or reverse cutting

• 2 basic configurations for curved needles

– Cutting: cutting edge can cut through tough tissue,

such as skin

– Tapered: no cutting edge; used for softer tissue inside

the body

Surgical NeedlesCutting Tapered

www.emedicine.medscape.com


Needle Anatomy

Surgical Instruments

Scalpel Blades


Instrument Holding

• Scalpel: Hold with the shaft of the scalpel in the

palm of the hand with the index finger on the top of

the blade

www.bumc.bu.edu

Instrument Holding

• Forceps should be held between the thumb and

index finger

• Needle driver: Place the thumb and finger slightly

into the instrument’s ring

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Wound Evaluation

• Time of incident

• Size of wound

• Depth of wound

• Tendon / nerve involvement

• Bleeding at site

When to Refer

• Deep wounds of hands or feet, or unknown depth of

penetration

• Full thickness lacerations of eyelids, lips or ears

• Injuries of nerves, larger arteries, bones, joints or

tendons

• Crush injuries

• Markedly contaminated wounds requiring drainage

Contraindications to Suturing

• Redness

• Edema of the wound

margins

• Infection

• Fever

• Puncture wounds

• Animal bites

• Tendon, verve, or vessel

involvement

• Wound more > 12° old

(body) and 24 °(face)

Wound Preparation

• Most important step for reducing the risk of wound infection

• Remove all contaminants and devitalized tissue before wound

closure

– Irrigate with Normal Saline

• If not, the risk of infection and of a cosmetically poor scar are

greatly increased

• Personal Precautions (Use sterile gloves)

Anesthetic Solutions

• Lidocaine (Xylocaine®) with epinephrine

– Vasoconstriction with ↓ bleeding

– Prolonged duration

– Strength: 0.5% & 1.0%

• Lidocaine (Xylocaine®)

– Most commonly used

– Rapid onset

– Strength: 0.5%, 1.0%, & 2.0%


• CAUTION !!! Due to its vasoconstrictive properties

never use lidocaine with epinephrine on:

– Eyes, Ears, Nose

– Fingers, Toes

– Penis, Scrotum


• Bupivacaine (Marcaine):

– Slow onset, long duration

– Strength: 0.25%

– DOSE: maximum individual dose 3mg/kg


Injection Techniques for the Anesthesia

• 25, 27, or 30-gauge

needle

• 6 or 10 cc syringe

• Check for allergies

• Insert the needle at the

inner wound edge

• Aspirate

• Inject agent into tissue

SLOWLY

• Wait…

• After anesthesia has

taken effect, suturing

may begin

Basic Laceration Repair

Principles And Techniqueswww.bumc.bu.edu

Types of Closure

• Simple interrupted closure – most commonly used, good

for shallow wounds without edge tension

• Continuous closure (running sutures) – good for

hemostasis (scalp wounds) and long wounds with

minimal tension

• Locking continuous - useful in wounds under moderate

tension or those requiring additional hemostasis

Types of Closure

• Subcuticular – good for cosmetic results

• Vertical mattress – useful in maximizing wound eversion,

reducing dead space, and minimize tension across the

wound

• Horizontal mattress – good for fragile skin + high tension

wounds

• Percutaneous (deep) closure – good to close dead space

+ decrease wound tension

Langer’s Lines

Simple Interrupted

• Most commonly used in the closure of skin

• Individual stitches placed and tied

• Perform if worried about the cleanliness of the

wound

– A few sutures can be removed easily if needed

• Can be used in all areas but takes more time

Simple Interrupted

Continuous Suture

• Place the sutures again and again without tying each

individual suture

• If clean wound, quicker and easier to bring edges

together

• Used for rapid closure of longer wounds and to stop

bleeding from skin edges

Continuous Interlocking

Vertical Mattress

Good for everting wound edges (neck, forehead creases, concave surfaces)

Vertical Mattress

Horizontal Mattress

Good for closing wound edges under high tension,and for hemostasis

Horizontal Mattress

Principles And Techniques

• Minimize trauma in skin handling

• Gentle apposition with slight eversion of wound edges

– Visualize an Erlenmeyer flask

• Make yourself comfortable

– Adjust the chair and the light

• Change the laceration

– Debride crushed tissue

Suturing

• Apply the needle to the needle driver

• Clasp needle 1/2 to 2/3 back from tip

www.bumc.bu.edu

Suturing

• Rule of halves:

– Matches wound edges better; avoids dog ears

– Vary from rule when too much tension across wound

1

Suturing

Rule of halves

Suturing

• The needle enters the skin with a 1/4-inch bite from

the wound edge at 90 degrees


Suturing

• Release the needle from the needle driver, reach

into the wound and grasp the needle with the needle

driver

• Pull it free to give enough suture material to enter

the opposite side of the wound

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1 2

34

Suturing

• Use the forceps and lightly grasp the skin edge and arc

the needle through the opposite edge inside the wound

edge taking equal bites

• Rotate your wrist to follow the arc of the needle

• Principle: minimize trauma to the skin, and don’t bend

the needle

– Follow the path of least resistance

Suturing

• Release the needle and grasp the portion of the needle

protruding from the skin with the needle driver

– Pull the needle through the skin until you have

approximately 1 to 1/2-inch suture strand protruding form

the bites site

• Release the needle from the needle driver and wrap the

suture around the needle driver two times

Suturing

• Grasp the end of the suture material with the needle

driver and pull the two lines across the wound site in

opposite direction (this is one throw)

• Do not position the knot directly over the wound

edge

Suturing

• Repeat 3-4 throws to ensuring knot security

• On each throw reverse the order of wrap

• Cut the ends of the suture 1/4-inch from the knot

• The remaining sutures are inserted in the same

manner

The Trick to an Instrument Tie

• Always place the suture holder parallel to the wound’s

direction

• Hold the longer side of the suture (with the needle) and

wrap OVER the suture holder.

• With each tie, move your suture-holding hand to the

OTHER side.

• By always wrapping OVER and moving the hand to the

OTHER side = square knots!!

The Knot

• Weakest point of the suture ligature

• Reduces the tensile strength of the suture by 30-35

%

• The surgeon must have a good working knowledge of

the characteristics of the sutures he employs and the

knots he uses

Categories of Knots

• Flat knots: Square, surgeon’s and granny

– Tied with half hitches with equal tension on each

segment of the suture

• Sliding knots: Identical and non-identical

– Half hitches tied with greater tension on one segment

of the suture

Sliding Knots

• Most surgeons use sliding knots rather than square knots

because:

– Crossing the Surgeons hands, sometimes required for

square knots, leads to slippage

– Tying deep ligatures is best accomplished by keeping

constant tension on the sutures

– Sliding knots require one more throw than square knots

Number of Knots

• Monofilament sutures require more knots

(knot slippage results in disruption)

- Usually five to six knots required

• Coated sutures require more knots

• Chromic requires “three squares” or four slip knots

• Dexon or Vicryl requires four squares or five slip knots

with “long tails”

Number of Knots (Throws)

• Chromic: Three squares or four slip knots

• Braided: (Dexon, Vicryl): four squares, five slip

knots

*Monofilament: (Prolene, Maxon, PDS, Nylon)

five squares or six slip knots

Suturing – Finishing

• After sutures are placed, clean the site with normal saline

• Apply small amount of Bacitracin and cover with a sterile non-

adherent dressing

• Need for Tetanus globulin or vaccine?

– Dirty versus clean

– Prior Immunization history

• Have patient return in one day for recheck, for signs of

infection or complications

Tetanus Prophylaxis

• Every 5 year update for tetanus toxoid is a

good rule on all cases

• Also use tetanus immune globulin) if:

– Patient never immunized

– Immunosuppressed

– Allergic or severe local reaction of toxoid

Patient Instructions for Follow-Up

• First 24-48 hours, patients should gently wash the wound

with soap and water, dry it carefully, apply topical

antibiotic ointment, and replace the dressing/bandages

• Facial wounds generally only need topical antibiotic

ointment without bandaging

• Eschar or scab formation should be avoided

• Sunscreen spf 30 should be applied to the wound to

prevent subsequent hyperpigmentation.

Suture Removal GuidelinesWound Location Suture Removal (Days)

Scalp 7

Face 3-5

Chin 7

Trunk 7-10

Arm 7-10

Hand 10-14

Leg 10-14

Sole of Foot 14-21

Any suture with pus or signs of infections should be removed immediately

Suture Removal

• Clean with hydrogen peroxide to remove any crusting

• Using pickups , grasp the knot and snip the suture

below the knot, close to the skin

• Pull the suture line through the tissue (in the direction

that keeps the wound closed) and place on a 4x4 --

count them

• Most wounds have < 15% of final wound strength after

2 wks – apply steri-strips

Staples

• Rapid closure of wound

• Easy to apply

• Evert tissue when placed properly

Topical Adhesives

• Indications: Selected approximated, superficial, clean wounds

especially face, torso, limbs

– May be used in conjunction with deep sutures

• Benefits:

– Cosmetic, seals out bacteria, apply in 3 min, holds 7 days

(5-10 to slough), seal moisture, faster, clear, convenient,

less supplies, no removal, less expensive

Topical Adhesives

• Contraindications:

– Infection

– Gangrene

– Mucosal, damp or hairy areas

– Allergy to formaldehyde or cryanoacrylate

– High tension areas

Dermabond ®

• A sterile, liquid topical skin adhesive

• Reacts with moisture on skin surface to form a

strong, flexible bond

• Only for easily approximated skin edges of wounds

– Punctures from minimally invasive surgery

– Simple, thoroughly cleansed, lacerations

www.product-finder.net

Dermabond®

• Standard surgical wound prep and dry

• Crack ampule or applicator tip up; invert

• Hold skin edges approximated horizontally

• Gently and evenly apply at least two thin layers on

the surface of the edges with a brushing motion

– At least 30 sec between each layer, hold for 60 sec after

last layer until not tacky and apply dressing

Follow Up Care with Adhesives

• No ointments or medications on dressing

• May shower but no swimming or scrubbing

• Sloughs naturally in 5-10 days, but if need to remove

use acetone or petroleum jelly to peel but not pull

apart skin edges

• Pt education and documentation

Any Questions??

Basic Suturing Workshop By Shauna O’Sullivan Resident Orientation Course 2012.

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Transcript of Basic Suturing Workshop By Shauna O’Sullivan Resident Orientation Course 2012.